Learning, Part Two

Updated 3/2017 -- photos and all links removed as many no longer active. 

I have now completed three weeks at my new job with the Disability Determination Services office.  I sort of knew there were two types of disability payments under SSI:  Title II and Title XVI.  Now I understand the differences much clearer.

I would urge everyone who can afford it to purchase disability insurance.  As the person training me put it, “If you are disabled, you are still ‘costing’ your family in addition to not contributing to the family income.”

The big difference between the two (II and XVI) is that anyone who has worked and paid taxes has in effect purchased disability insurance (Title II – DIB).  Title II is not based on your I & R (income and resources) as you are insured.  Title XVI individuals are the truly poor who must meet an I& R test. 

Both Title II and Title XVI must the SSI definition of a disability to be eligible:  The individual must not be able to perform substantial gainful activity (SGA) due to a medically determinable impair (MDI) which can be substantiated by a medical consultant backed up by significant signs, symptoms, and laboratory data.  The MDI had to be one which is expected to result in death or which has lasted or will last 12 months.

The person training me is blind (due to RP).  Note he does not meet the able definition as he is working.  He is an amazing person who was a pediatrician prior to taking a job with DDS as his sight began to go.  He uses a program called JAWS to read to him at work, but types faster than I do.  He has the listings memorized.

Shout Outs

Updated 3/2017:  photos and all links removed as many no longer active and it was easier than going through each one.

Shrink Rap is the host for this week’s Grand Rounds.  You can read this week’s Summer Solstice “Hot” edition here.

Shrink Rap is hosting our third Grand Rounds today on June 21, which is the first day of Summer. In keeping with the summer solstice theme, we asked for submissions that have a theme of "hot." However, "hot" may refer to not just  temperature, but also spiciness, luck, passion, anger, popularity, etc.

Our first Grand Rounds in 2007 featured a clicky brain, and the second featured the then-new iPhone 3G, complete with clicky iPhone apps. This time, we've used clicky pictures that exemplify the "hot" theme. . ……..

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Yesterday,  NPR ran this  article by Alix Spiegel on inattentional blindness:  Why Seeing (The Unexpected) Is Often Not Believing

……The goal of all this was to answer a question: Is it possible to see something really, really obvious and not perceive it?  …….

When psychologists Chabris and Simons ……..They do research on something called inattentional blindness, or how people fail to see things that are directly in front of them when they're focused on something else. And in Conley they felt they had found a compelling example.  ……….

This topic is important to patient safety as seen in this article:  Inattentional blindness: What captures your attention?

A nurse pulls a vial of heparin from an automated dispensing cabinet (ADC). She reads the label, prepares the medication, and administers it intravenously to an infant. The infant receives heparin in a concentration of 10,000 units/mL instead of 10 units/mL and dies. ……

Expectation has a powerful effect on our ability to pay attention and notice information. If the medication we are looking for comes in a carton with a highly stylized label, we come to expect this presentation every time we look for the medication…….

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Dr. Cynthia Bailey has a nice post on sunburn:  What is a sunburn?  

A sunburn tells you that damage and inflammation have happened inside your skin from UV exposure; you exposed yourself to more sun than your skin type can handle…..and there’s simply no good news about it!   ….

In this Sunburn Series I’m going to give you a dermatologist’s explanation of what happens in your skin when you get

• a sunburn (i.e. why it’s red and hurts)
• a tan (i.e. how much sun protection you get from one)

I’m also going to give you some helpful information to heal sunburned skin and explain how to prevent ever getting a sunburn again. …….

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Dr Val, Better Health, is now hosting a radio show called, "Healthy Vision with Dr. Val Jones."  It is currently available here on iTunes.  The show has three segments (one about the importance of regular eye exams, one about contact lens care, and one about UV protection for eyes). It's available as a full show (20 minutes) and as individual segments.

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Dr. Kathryn Clancy, Assistant Professor of Anthropology at the University of Illinois, answers the question:  Why do we menstruate?

…..I will answer three different ones for you: Why do we menstruate? What did we do back in the day? and What is appropriate today?

Why do we menstruate?

Humans are not the only animals to undergo cycles of growth and regression in our endometrial lining. Yet, only a few animals actually menstruate. Menstruation has occasionally been observed in other great apes (this is the primate group where humans belong, with the chimps, bonobos, gorillas and orangs), and a few other animals. As far as we can tell, everyone else resorbs the lining before growing a new one. It seems to be that those animals who menstruate, do so because the amount of lining they have is greater than what they are able to resorb.  …….

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Dr. Lisa, Call Me Dr. Lisa, write about her relationship with her physical therapist:   An S&M relationship for good!  (photo credit)

I’m in a Sadistic/ Masochistic relationship, and I like it.  Now don’t get any crazy ideas, but really I let this guy strap electrodes to my leg, put me in a 40 pound flack jacket and then do exercises, and that is just the beginning.  Yep, I’m talking about my physical therapist.  Still I go back twice a week because he knows what he’s doing and I’m getting better.  ………

I go, I go twice a week.  I spend 3 +/- hours there and I do whatever he says.  My reward, today he had me run on a treadmill.  5 months after my surgery and I’m starting to run again.  I’m well on the road back.  It feels great.  I’m good with this S&M thing we have going on! ……..

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Sarah McFarland, Threads Magazine, has a piece announcing:  New Sewing Show, "It's Sew Easy," Starts June 30 on PBS

You may have heard about it through the sewing grapevine, but now it's nearly here - the premiere of "It's Sew Easy" is June 30 on PBS stations across the country. It's great news when a national audience is exposed to the fun of sewing!

"It’s Sew Easy" replaces "America Sews with Sue Hausmann," promising to give faithful viewers a new spin on sewing where America Sews left off.  …….

Propranolol Treatment for Infantile Hemangiomas

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

The Plastic and Reconstructive Surgery Journal article from 2009 (second reference below) spurred Will J. M. Holmes, M.R.C.S and colleagues to write a letter to the journal noting their experience with propranolol in the treatment of infantile hemangiomas.

Holmes cited two articles (references 3 and 4 below) which report the efficacy of of β-blockers in the treatment of hemangioma.

As part of a larger study, we have used propranolol in a total of 15 patients. So far, we have observed signs of rapid involution of hemangioma within the first week of treatment in all patients. The response rate is faster than those we have seen when corticosteroids are used. In addition to stopping the proliferation of hemangiomas, propranolol also causes rapid involution within a short period.

We now offer propranolol as a first-line treatment to all rapidly proliferating hemangiomas with functional deficit and/or disfigurement. We have developed a treatment protocol in conjunction with the cardiologist that involves pretreatment cardiac workup and an in-hospital titration of propranolol up to 1 mg/kg three times per day. So far, we have not needed to increase the dosage to more than 1 mg/kg three times per day.

Their treatment protocol is referenced to the 5th article below.
Related post:  Propranolol for Hemagiomas?  (March 4, 2009)


REFERENCES

1.  Propranolol as First-Line Treatment for Infantile Hemangiomas (Letter); Holmes, Will J. M. M.R.C.S.; Mishra, Anuj M.R.C.S.; Gorst, Cath R.G.N., R.S.C.N.; Liew, Se-Hwang F.R.C.S.; Plast & Reconstr Surgery: January 2010 - Volume 125 - Issue 1 - pp 420-421; doi: 10.1097/PRS.0b013e3181c2a731

2.     Classification of Vascular Anomalies and the Comprehensive Treatment of Hemangiomas;  Burns AJ, Navarro JA, Cooner RD.; Plast Reconstr Surg. 2009;124(1 Suppl.):69e–81e.

3.    Propranolol for severe hemangiomas of infancy; Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, et al.;  N Engl J Med. 2008;358:2649–2651. (pdf)

4.      Beta-blocking Agent for Treatment of Infantile Hemangioma; Bigorre M, Van Kien AK, Valette H. . Plast Reconstr Surg. 2009;123:195e–196e.

5.      More on Propranolol for Hemangioma of Infancy; Siegfried EC, Keenan WJ, Al-Jureidini S. . N Engl J Med. 2008;359:2846–2847.

6.       Ulcerated Hemangiomas of Infancy: Risk Factors and Management Strategies; eLiterature Review (John Hopkins Medicine) , Oct 2007, Vol 1, No 4; Bernard A. Cohen, MD, Susan Matra Rabizadeh, MD, MBA, Mark Lebwohl, MD, and Elizabeth Sloand, PhD, CRNP

Dynamed/Skyscape

Updated 3/2017--  all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

A week ago I attended a lunch lecture on Mobile Medical Apps given by Krystal Boulden, MLIS at UAMS.  I knew about most of the ones she talked about:  Epocrates, Clini-eGuide, PubMed on Tap, PubMed for Handhelds, and RefWorks.  Of those, I only use Epocrates.
The one I didn’t know was the first one she highlighted:  Dynamed (the actual app is Skyscape).

DynaMed - Clinical reference tool provided by the University of Arkansas for Medical Sciences (UAMS) Area Health Education Centers' Libraries (AHEC), Arkansas Children's Hospital Library, and the UAMS Library. Registration is required for access and renewal is required annually. Training is available through the Area Health Education Centers' Libraries and the UAMS Library. To register for DynaMed click here. To access DynaMed click here.

DynaMed is free to use, but registration is required.  It is evidenced-based, often with links to related articles.  It provides information related to the disease, diagnosis, and treatment.  I have only recently registered and been given my user/password, but with the limited “playing” around I have found it full of useful information. 

The medical app, Skyscape, is free for download from iTunes.

Choose content from top publishers, current guidelines, drug guides, interactive algorithms, calculators and much more.

Skyscape can help you find the information you are looking for:

Table of Contents Search

Incremental Search
SmartSearch™
History
Related Topics
SmartLink™

I haven’t downloaded the app so I can’t give you a personal review.  If anyone has used it, what do you think?

Looking around the UAMS Library website it appears I have not been taking full advantage of the resources they offer:

Online Resources
·  eResources | eJournals
·  eBooks | eReserves
·  Clinical Resources
·  UAMS Library Catalog
·  Mobile Devices
·  HRC Digital Collection
· Image Resources

On twitter:

@UAMS

@UAMSlibrary

Shout out to a couple of guys from MD2P.net whom I met at the meeting:  Simon Lee (@simonslee) and John Malone (@JJMal_One )

FTM Chest Contouring – Lessons Learned

I wrote a post, Chest Wall Contouring in Female-to-Male Transsexuals, in December as I prepared to do my first such surgery.  I was up front with him about him being my first FTM though not my first mastectomy.

Well, I had to perform a second procedure to correct the first.   Here is what I learned from this experience:

1.  A minimal scar is not worth having extra skin remain.  

I opted for the first surgery to use a peri-areolar incision/scar feeling it would allow enough skin excision and leave less of a scar.  The scar was smaller, but even after months to allow full contraction of the remaining skin turns out not enough skin excision.

The extended concentric circular scar looks good with a nice chest contour.

2.  The inframammary crease must be fully obliterated.

I knew this from my reading.  I thought I had done so.  I recommend freeing up the skin from the chest wall a good 2 inches below the marked crease to ensure it’s destruction.

3.   Use drains.

No matter how well you think you have controlled the hemostasis.

 

I am happy with the results after the revision.  The patient is too if his smile and statement are any indication -- “I can now look at my chest without revulsion.”

Raynaud’s Phenomenon of the Nipple

Updated 3/2017 -- photo and all links removed as many no longer active and it was easier than checking each one.

This article would have been off my radar had it not been for the interaction on twitter.

jeffreyleow RT @paulinechen: Camera Phones [patients taking pics] helps doctor make rare diagnosis http://3.ly/CXr (via @EllenRichter)

Granted I am not generally asked about nipple pain in pregnant women.  Those questions tend to go to folk like TBTAM or ER’s Mom. 
The article describes a case report of a 25 yo woman in her 2nd trimester with “frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her to tears.”

The article discusses Raynaud’s phenomenon of the nipple and share these photos (credit) taken with a camera phone with us.  The text with the photo:

Vasospasm of the arterioles manifesting as pallor (left), followed by cyanosis, and then erythema (centre). The right hand image shows the normal, asymptomatic, status.

As with Raynaud's of the hand (which I am more familiar with), the phenomenon tends to occur when the ambient temperature drops below a certain threshold that is specific to each individual.  Exposure to cold should be avoided, as is avoidance of caffeine, nasal vasoconstrictors, and tobacco.
Additional treatment for Raynaud’s of the nipple:

Women with persistent pain require immediate relief to continue breastfeeding successfully. Recommended treatment is 30 mg nifedipine of sustained-release once-daily formulation, and most women respond within two weeks.

REFERENCE
An Underdiagnosed Cause of Nipple Pain Presented on a Camera Phone; BMJ 2009;339:b2553; O L Holmen, B Backe
Vasospasm of the Nipple–a manifestation of Raynaud's phenomenon: case reports; BMJ 1997 314: 644; Laureen Lawlor-Smith and Carolyn Lawlor-Smith

Dermatitis and Eczema – an Article Review

Updated 3/2017-- all links removed as many are no longer active and it's easier than checking each one.

Being a plastic surgeon, I have a great interest in the skin and no I don’t see or treat much dermatitis as the primary physician.  Patients do occasionally ask me about patches / rashes they have.  It’s always nice to be up on the topic and to know when it’s important to make sure they see a dermatologist.

The article listed below is a nice, simple  review of conditions that fall into the eczema / dermatitis categories.  The article discusses atopic dermatitis (AD), nummular (coin-shaped)eczema,  contact dermatitis, and stasis dermatitis.  It is not a deep article on the subject, but did include some nice reminders and tips.

The article points out that allergic dermatitis is not uncommon in patients with chronic wounds.  They site an article which documented more than 51% of leg ulcer patients acquire contact allergic dermatitis to local dressings and other topical treatment.  This is important to any of us who treat wounds, acute or chronic.  Sometimes the wound fails to heal due to this.

There is a nice table which lists the common allergens in patients with chronic wounds.  If your chronic wound patient has a contact allergy to these products, it can certainly complicate their wound healing.

• lanolin (common in moisturizing creams and ointments)
• perfumes/fragrances
• cetylsterol alcohol (used as an emulsifier, stabilizer, and preservative in creams, ointments, and paste bandages)
• preservatives:  quaternium 15, parabens, chlorocresol  (all are used to prevent bacterial contamination in creams, but are not in ointments)
• rosin (colophony)  -- a component of some adhesive tapes, bandages, or dressings
• rubber / latex

Key to treatment and prevention of future exacerbations is identification of any provocative factors so that they may be avoided as there is no absolute cure for dermatitis.   Here is a summary of tips the article gives:

Laundry and Clothing Suggestions

• Avoid wearing wool or nylon next to their skin as they may exacerbate itch.  Choose materials made of cotton or corduroy which are softer.
• Rather than use fabric softeners and bleach, which may be irritating to the skin, add a white vinegar rinse in the washing machine rinse cycle cup/dispenser to remove excess alkaline detergent.

Moisturizers

• Keep water exposure to a minimum.
• Use humectants or lubricants regularly to replenish skin moisture.  Apply these agents immediately after bathing while the skin is damp.
• For severe hand eczema, cotton gloves may be worn at night to augment the moisturizing effect of humectants and other topical treatments.

Topical Steroids

• Topical steroids continue to be the mainstay therapy for treating dermatitis.
• Topical steroid creams can be kept in the refrigerator or combined with 0.5% to 1% of menthol (camphor and phenol are alternatives) to give a cooling effect.   This often helps.
• Treat the dermatitis with a topical steroid when the skin is red and inflamed.  Tapering the topical steroid use by alternating  with moisturizers as the dermatitis resolves.
• Remember that  percutaneous absorption of topical steroids is greatest on the face and in body folds.  They suggest only weak or moderate preparations be used in these areas.
• Moderate to potent topical steroids should be used on the trunk and the extremities.
• The palms and soles are low-absorption areas, so may require very potent topical steroids

REFERENCE

The ABCs of Skin Care for Wound Care Clinicians: Dermatitis and Eczema; Advances in Skin & Wound Care: May 2009, Vol 22, Issue 5, pp 230-236;  Woo, Kevin Y. RN, MSc, PhD, ACNP, GNC(C), FAPWCA; Sibbald, R. Gary BSc, MD, MEd, FRCPC (Med, Derm), ABIM DABD, FAPWCA (doi:10.1097/01.ASW.0000350837.17691.7f)

Preventing & Managing Dry Eye Syndrome after Periorbital Surgery– an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Dry eye syndrome is a source of discomfort to many.   An estimated 3.23 million women and 1.68 million men in the U.S. aged 50 years and older are affected by this common disorder.  That’s an estimated 10-30% of the population.

The article to which the post title refers is the first one listed in the reference section below.  It is a retrospective review of charts for 202 consecutive patients (180 women and 22 men) who underwent upper and/or lower blepharoplasty (eyelid surgery).  Dry eye syndrome is a well-recognized problem  that every surgeon performing blepharoplasties will encounter, but try to minimize or avoid.  The article does a nice job of discussing key elements of perioperative care.  It outlines algorithms for detection, prevention, and management.

Simply put dry eye syndrome is caused by reduced tear production or excessive tear evaporation.  Symptoms can include mild irritation and itching and foreign body sensation. Other complaints may suggest a vague soreness or awareness of my eyes (not previously noted), ocular fatigue, and changes in visual function (blurred vision).

The article focuses on four areas:

Successful surgery and prevention of persistent dry eyes entails

(1) proper understanding of tear film anatomy physiology

(2) preoperative recognition of risk factors through the history and physical examination

(3) intraoperative maneuvers to maximize prevention

(4) immediate and aggressive postoperative management.

Understanding tear formation and the anatomy is important in the prevention.  Any surgical modification of the periocular anatomy can alter the eyelid closure and blinking mechanism which are so important in the “lubrication” of the ocular surface of the eye. 

Risk factors can be divided into systemic, pharmacologic, environmental, and anatomical.  The article has a nice list of all four categories.

A thorough history and physical examination is essential.  The patient should be asked about signs and symptoms of dry eyes and their successful (or not) use of contact lenses.  Questions covering the risk factors (ie Rheumatoid arthritis, Sjogrens, use of anticholinergics, allergies).

Physical examination should include visual acuity measurements, document signs of dry eyes (ie erythema, epiphora, frequent blinking), and note any anatomical risk factors (ie  proptosis, lower lid laxity, scleral show, negative vector orbit, and lateral canthal dystopia).

They make the point that if any of these risk factors are present then one should consider delaying the operation or possibly not proceeding with surgery, depending on the degree of symptoms and risk. 

Their next section is on the surgical approaches in these patients.  It is a nice overview and if you do many blephroplasties you may want to read the entire review article, but here are a few of their tips and cautions:

Staging the upper and lower blepharoplasties in two separate operations may be considered.

Corneal protection is an obvious, often overlooked aspect of blepharoplasty.

Trauma or, more importantly, prolonged exposure can lead to corneal abrasion or ulceration.

Conservative excision is critical. This entails accurate measurement with a caliper and leaving 8 to 9 mm in the pretarsal fold when performing an upper blepharoplasty.

Skin resection in the lower blepharoplasty should be more conservative, taking into account that even if there is no lower lid retraction after resection, postoperative healing and scarring may eventually pull a lax lid down.

The orbicularis oculi muscle should be preserved in both upper and lower blepharoplasty. Special attention is paid to not injure the innervation as well. Disruption may lead to a decreased blink rate and is a setup for evaporative tear loss.

Canthopexy to correct lateral canthal depression and protect against ectropion is a safe measure that may be performed.

Postsurgical prevention of dry eyes is also very important.  It should be aimed at 1) limiting swelling, 2) maintaining hydration and lubrication, 3) controlling inflammation,  and 4) preventing infection. 

Edema may be controlled with head elevation and periorbital cool compresses.

Immediately after surgery, normal tear film production is disrupted and may take several days to recover.  Liberal use of artificial tears during the day and lubrication at night protect the eyes during this period.

Topical antibiotic and steroid (TobraDex; Alcon Labs, Fort Worth, Texas) drops help in reducing the inflammatory response and preventing conjunctivitis.

The systemic steroids are also continued by tapering oral corticosteroids over 5 days (Medrol Dosepak; Upjohn Co., Kalamazoo, Mich

Overall, an article well worth the time it takes to read and study it.

REFERENCE

Preventing and Managing Dry Eyes after Periorbital Surgery: A Retrospective Review; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 353-359; Hamawy, Adam H. M.D.; Farkas, Jordan P. M.D.; Fagien, Steven M.D.; Rohrich, Rod J. M.D.

Dry Eye Syndrome; eMedicine Article, Sept 26, 2008; C Stephen Foster MD, Erdem Yuksel MD, Fahd Anzaar MD, and Anthony S Ekong MD

Complications After Autologous Fat Injections to the Breast – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I reviewed a couple of articles on fat injections to the breast back in November.  Now I’ll like to review an article published in the January issue of the Journal of Plastic and Reconstructive Surgery  (PRS).  The full reference for the article is listed below.

The authors began by pointing out that autologous fat injection (fat grafting) to the breast has a history of being performed widely throughout the twentieth century, but  in 1987, the American Society of Plastic and Reconstructive Surgeons indicated that because of the side effects (i.e., tissue scarring, oil cysts, and calcification), autologous fat grafting to the breast might compromise breast cancer surveillance and should therefore be prohibited.  Most plastic surgeons stopped performing the procedure.  There were a few who continued to do the fat grafting to the breast and have published their results (several references given in this articles reference list).  As mentioned in the previous post, there are currently two clinical trials being done by Dr Scott Spear and Dr Roger Khouri. 

For any woman interested in being in one of the two clinical trials, you can find the information on the federal clinical trials Web site.

The authors had noticed that many of these breast augmentation procedures done using fat grafting are “performed incorrectly by untrained and untutored individuals.”   The paper was written to report on several cases of complications and to discuss the related issues.

The report is retrospective and involved 12 patients seen between 2001 and 2007.  The mean age of the women was 39.3 years.  All  the cases involved fat injections to the breast for cosmetic augmentation mammoplasty. The period from fat injection surgery to presentation ranged from 6 months to 6 years (mean, 3.25 years).   All of them presented with palpable indurations.  Others presented with pain (3), infection (1), abnormal breast discharge (1), and lymphadenopathy (1).   All patients were subjected to mammography, computed tomography, and magnetic resonance imaging to evaluate the injected fats.

Several cases were presented in detail with patient photos and radiographic photos, such as this one.

Case 2

A 37-year-old woman had undergone bilateral breast augmentation by autologous fat injection at a cosmetic clinic 3 years previously. Her breasts gradually became rigid and deformed, but she had no trouble with daily life. However, after having a child, she noticed an abnormal yellow secretion while breast-feeding. On her first visit to our facility, her breasts were clearly asymmetrical and deformed, and indurations were detected (Fig. 1). On mammography, computed tomography, and magnetic resonance imaging, large masses were detected in both breasts (Figs. 2 and 3). The tumors, which contained yellow fluid (Fig. 4), were removed surgically. Six months after the operation, both breasts were reconstructed with saline implants (Fig. 5). Abnormal breast secretion has not been observed since the masses were removed.

And this one (remember this study was done in Japan and I hope that the use of illegal silicone injection wouldn’t be done here in the U.S.)

Case 12

A 33-year-old woman underwent buttock liposuction and fat injection to the breast at a cosmetic clinic 2 years previously. After the operation, she became aware of indurations and disfiguration of both breasts and visited our facility. Asymmetry of the breasts and huge indurations were palpable (Fig. 18). On preoperative blood examination, high levels of antinuclear antibodies were detected. On mammography, huge masses were detected in the subcutaneous tissue (Fig. 19). Chest computed tomography revealed multiple low-density areas encapsulated with high-density areas in the subdermis in both breasts. Magnetic resonance imaging indicated multiple injected fat with high-iso signal intensity on T1-weighted images and low signal intensity on T2-weighted images (Fig. 20). Surgery to remove the subcutaneous masses was performed. Our routine examination for foreign bodies using nuclear magnetic resonance detected a small amount of silicone contamination. This suggests that the high levels of antinuclear antibodies in the blood may be the result of an immunologic reaction to silicone (human adjuvant diseases). These observations suggest that the patient had been injected with silicone at the time of surgery without her consent.

They give a very nice discussion of fat injection which includes some history

It appears that fat injection was first performed in 1893, when the German physician Franz Neuber9 used a small piece of upper arm fat to build up the face of a patient whose cheek bore a large pit caused by a tubercular inflammation of the underlying bone.

and continues to remind the reader of the virtual moratorium imposed in 1987, American Society of Plastic and Reconstructive Surgeons when the society recommended that autologous fat grafting to the breast be prohibited because of the relatively frequent occurrence of complications that compromised breast cancer screening.   They point out that this has resulted in little scientific literature or discussion on the procedure. 

As a result, there remains a dearth of studies examining the long-term safety and efficacy of this technique. This technology, especially with regard to its use in breast augmentation, must be tested by multi-institutional long-term studies with careful breast cancer surveillance.

They make the valid point the procedure continues to be performed even without good long-term outcome studies.

We believe that this has resulted in many victims, who are exemplified by the 12 patients that we have described in this article. The problems associated with this inadequately tested procedure are also exacerbated by a widespread decline in the skills of aesthetic surgeons because of the influx of many untrained and unskilled individuals, especially in some Asian countries, including Japan.

The complications associated with autologous fat grafting to the breast are well known, and include calcifications and oil cysts.  These calcifications may mask or cover the microcalcifications associated with carcinomas.  Remember fat grafting is “grafting” and there can be fat necrosis.

I admire their conclusions paragraph:

Autologous fat grafting to the breast is not a simple procedure and should be performed by well-trained and skilled surgeons. Patients should be informed that it is associated with a risk of calcification, multiple cyst formation, and indurations, and that breast cancer screens will always detect abnormalities. Patients should also be followed up over the long-term and imaging analyses (e.g., mammography, echography, computed tomography, and magnetic resonance imaging) should be performed.

Previous Post on Topic
Fat Injections for Breast Augmentation (November 6, 2008)

REFERENCE

Complications after Autologous Fat Injection to the Breast;  Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 360-370; Hyakusoku, Hiko M.D., Ph.D.; Ogawa, Rei M.D., Ph.D.; Ono, Shimpei M.D.; Ishii, Nobuaki M.D.; Hirakawa, Keiko Ph.D

Be a Potential Hero – Learn CPR

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it's easier than checking each one. 

Earlier this month the Arkansas Legislators passed a bill to put AED devices in all public schools in our state. The bill was sponsored by Senator Tracy Steele. It is estimated that about $1 million dollars will be needed to pay for the devices. The money is expected to come from the recently passed increased tobacco tax (an extra 56 cents per pack).

The Antony Hobbs III Act was named in honor of 17 yr Parkview High School basketball player who died after collapsing at a game. He died of complications from an undiagnosed heart defect.

I renewed my ACLS this past Thursday evening. Some of my nurse friends ask me to go with them as a way of getting together. They needed to recertify and assumed I might. We meet for dinner before the class and enjoyed the time together.

During the evening, the EMT who reviewed the AED devices with us mentioned having responded to the collapse of Antony Hobbs. He wanted to stress the importance of knowing basic CPR and BLS as most arrthymias are not shockable. He ask if we wanted to guess how many people at the basketball game attempted to help.

Can you guess?

When the crowd was asked if there were any medical folks there, one nurse stood up and responded. None of the teachers, coaches, parents responded “I know CPR. Can I help?”

I found that sad. CPR is much more important in most life situations than ACLS. I would like to encourage all to learn CPR. Even if the AED finds a shockable rhythm, the recommendation is a minimum of 2 minutes of good quality CPR immediately after the shock even if a normal rhythm is seen.

So having the AEDs in airports, in schools, at your work place does not replace the need for CPR. We all need to know how to do good quality CPR. It is the CPR that is most likely to save some one.

It is easy to find classes. Look to your local Red Cross chapter. They have classes on a regular basis to teach basic CPR and AED use. Or contact a group like America First Response.

Get your entire family to take the class. Learn CPR --you might end up being a hero.

Sources

Arkansas Online

Red Cross CPR Classes

American First Response

Requirement of Perioperative Stress Doses of Corticosteroids -- an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it's easier than checking each one. 

If you refer back to my November 3, 2007 post you will see that I was taught that patients on long term corticosteroids need to have “extra” doses or “stress” doses of corticosteroids perioperatively. It was nice to see this recent article in the Archive of Surgery Journal (full reference below). The logic of the perioperative stress doses is to cover the impaired response to the stress of surgery and anesthesia due to the suppression of hypothalamic-pituitary-adrenal axis (adrenal insufficiency) that happens with prolonged corticosteriod use.

Their stated objective was

To determine the requirement for perioperative supplemental (stress) doses of corticosteroids in patients receiving long-term corticosteroid therapy and undergoing a surgical procedure.

They chose to do a review of the literature, looking for all relevant clinical trials that studied the role of perioperative corticosteroids and adrenal crisis in patients taking long-term therapeutic doses of corticosteroids. They searched the National Library of Medicine's MEDLINE database for relevant studies in any language published from January 1, 1966, through July 31, 2007. Keywords for the search were perioperative care or perioperative or surgery and adrenal cortex hormones or corticosteroids. The search was limited to studies involving humans and adults.

They found nine studies that meet their requirements. They studies involve a total of 315 patients who underwent 389 surgical procedures.

Two of the studies were prospective, double-blind, randomized, placebo-controlled studies in which patients received perioperative stress doses of corticosteroids or placebo together with their usual maintenance dose of corticosteroid.

In 2 studies, corticosteroid therapy was stopped before surgery (18 and 36 hours before surgery). Stress doses of corticosteroids were not administered.

In an additional 5 studies patients were followed up after receiving only their usual daily maintenance dose of corticosteroid. Stress doses of corticosteroids were not administered.

Their results

The 2 randomized placebo-controlled studies included in this review did not detect a difference in the hemodynamic profile of patients treated with stress doses of corticosteroids compared with patients treated with their usual dose of corticosteroid alone.

These results are supported by the 5 cohort studies in which patients received their usual daily dose of corticosteroid without the addition of stress doses of corticosteroids; none of the patients in those 5 studies developed an adrenal crisis.

One patient in each of the studies by Jasani et al and Kehlet and Binder developed a possible adrenal crisis that responded rapidly to hydrocortisone treatment; in those patients, corticosteroid therapy was stopped 36 and 48 hours before surgery.

Their conclusion is that the data suggest patients receiving long-term corticosteroid therapy do not require stress doses of corticosteroids. They stress that these patients should continue to receive their usual daily dose of corticosteroid.

They also stress

These recommendations do not apply to patients who receive physiologic replacement doses of corticosteroids because of primary dysfunction of the HPA axis (eg, patients with primary adrenal failure due to Addison disease, with congenital adrenal hyperplasia, or with secondary adrenal insufficiency due to hypopituitarism). It is likely that these patients are unable to increase endogenous cortisol production in the face of stress. These patients require adjustment of their glucocorticoid dose during surgical stress under all circumstances.

REFERENCE
Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Literature; Arch Surg, Dec 2008; 143: 1222 – 1226; Paul E. Marik; Joseph Varon

Perioperative Steroid Coverage (my blog post; November 3, 2007)

Propranolol for Hemagiomas?

 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

There is an article (see reference below) in the June 12, 2008 issue of the New England Journal of Medicine (h/t Medpage Today) that shows some amazing regression of hemagiomas using propranolol.

Hemangiomas of infancy are the most common tumor of infancy. They typically appear within a few weeks after birth and peak within three months. Hemagiomas are more common in girls than boys, more common in white than other races, and more common in preemies. Most of these lesions are innocuous and regress without treatment. Up to 75% shrink to insignificance by the time the child reaches school age. However, 5-10% of the lesions that will ulcerate during the rapid growth phase in the first 6 months of life. Ulceration is the most common reason for referral to specialists, and may be associated with pain, bleeding, infection, disfigurement, and scarring.

This one series of photos shows the results:

Panel A shows the patient at 9 weeks of age, before treatment with propranolol, after 4 weeks of receiving systemic corticosteroids (at a dose of 3 mg per kilogram of body weight per day for 2 weeks and at a dose of 5 mg per kilogram per day for 2 weeks).

Panel B shows the patient at 10 weeks of age, 7 days after the initiation of propranolol treatment at a dose of 2 mg per kilogram per day while prednisolone treatment was tapered to 3 mg per kilogram per day. Spontaneous opening of the eye was possible because of a reduction in the size of the subcutaneous component of the hemangioma.

Panel C shows the patient at 6 months of age, while he was still receiving 2 mg of propranolol per kilogram per day. Systemic corticosteroids had been discontinued at 2 months of age. No subcutaneous component of the hemangioma was noted, and the cutaneous component had considerably faded. The child had no visual impairment.

Panel D shows the child at 9 months of age. The hemangioma had continued to improve, and the propranolol treatment was discontinued.

Christine Léauté-Labrèze, M.D., of Bordeaux Children's Hospital, and colleagues used the drug to treat two infants with heart disease (one with cardiomyopathy, the another with increased cardiac output) who just happened to also have hemangiomas. Unexpectedly, the lesions began to fade. They then used propranolol on nine other children with hemangiomas with similar success.

Johns Hopkins researchers have developed a protocol for the beta-blocker as a first-line treatment for the skin disorder. Propranolol could replace or supplement steroids such as prednisone which are often used currently. The children receive 1 mg/kg of propranolol on the first day, divided over three doses, and 2 mg/kg -- also divided in thirds -- after that.

Prednisone use carries the side effects of growth retardation, elevated blood sugars, and reduced resistance to infection.

Propranolol has side effects that include hypotension and hypoglycemia, but these are short-lived.

So far, Dr. Cohen and Katherine Puttgen, M.D., also at Johns Hopkins, say they have treated 20 patients with propranolol. Working with cardiologists, they decided to hospitalize the infants for the first two days of treatment to monitor for possible side effects such as hypotension or hypoglycemia. (They have seen none so far.)

Dr. Léauté-Labrèze, and colleagues reported that they are applying for a patent for the use of beta-­blockers in infantile capillary hemangiomas.

REFERENCES
Propranolol for severe hemangiomas of infancy; New Engl J Med 2008; 358: 2649-2651; Léauté-Labrèze, C et al
Ulcerated Hemangiomas of Infancy: Risk Factors and Management Strategies; eLiterature Review (John Hopkins Medicine) , Oct 2007, Vol 1, No 4; Bernard A. Cohen, MD, Susan Matra Rabizadeh, MD, MBA, Mark Lebwohl, MD, and Elizabeth Sloand, PhD, CRNP
Related Blog Posts
Vascular Birthmarks (July 15, 2007)
Early Surgical Intervention for Proliferating Hemagiomas of the Scalp -- An Article Review (Sept 1, 2008)

Prevention and Management of Complications of Rhinoplasty – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This article is a CME (continuing medical education) article.  As such it is a review of complications of rhinoplasty.  It is a good review and worth reading.

Complications of rhinoplasty can be classified into hemorrhagic, infectious, traumatic, functional, or aesthetic problems.  Here is a  summary of the article.

Hemorrhagic Complications

Postoperative bleeding is one of the most common
complications following nasal surgery. 

Epistaxis  --  The most common causes of mild epistaxis are bleeding from the incision sites and traumatized
mucosa.

For mild to moderate epistaxis being with

• 60-degree head elevation
• gentle nostril pressure for 15 minutes
• application of topical decongestant nasal sprays such as oxymetazoline or phenylephrine.

If bleeding persists

• Remove the septal splints and gently suction the nasal passages remove blood clots and crusts.
• Cauterize focal areas of bleeding with silver nitrate or place a light hemostatic packing made of methylcellulose over the bleeding surface.

Continued bleeding may require a formal nasal pack, either in the form of gauze or a commercially available nasal tampon.
Bleeding that persists despite anterior packing may signify
a posterior bleed from a branch of the sphenopalatine
artery.  If so, a posterior pack may be required. 

• Patients should be observed for airway compromise while a posterior pack is in place.
• Antibiotics should be administered while packing is in place to reduce the risk of toxic shock syndrome.

Serious bleeding occurs in less than 1 percent of patients, but warrants operative exploration when conservative measures fail.

Septal Hematoma -- is a potentially serious complication of rhinoplasty.  These patients may present with symptoms of nasal obstruction, pain, rhinorrhea, or fever.   The typical finding on physical examination is an ecchymotic nasal septal mass.

Untreated septal hematoma may lead to cartilage necrosis with subsequent loss of dorsal support and a saddle-nose deformity.

Management

• early recognition with prompt evacuation of the hematoma, either via needle aspiration or incision and drainage.
• Antimicrobial therapy should be initiated if a secondary nasal septal abscess is suspected.

Infectious Complications

Postoperative infections following rhinoplasty can range in severity from mild cellulitis of the soft tissue envelope to life-threatening systemic illness resulting from cavernous sinus thrombosis or toxic shock syndrome.

Local wound infections (such as cellulitis) -- treat with systemic antibiotics and close observation.

Abscesses require prompt surgical drainage in addition to antibiotic therapy. Common sites of abscess formation following
rhinoplasty include the nasal dorsum, nasal tip, and septum.

Cavernous sinus thrombosis,  meningitis, or a brain abscess may result without adequate treatment of a septal abscess.

Toxic shock syndrome is an acute, multisystem disease.  It has been described after nasal surgery with the use of both nasal packing and intranasal splints.   Symptoms occur early and can include nausea or vomiting, rash, fever, tachycardia, and hypotension.  Treatment requires the immediate removal of the offending object (packing or splint), intensive care unit admission, intravenous antibiotics, and supportive care.

Traumatic Complications

L-Strut Fractures  -- 
When L-strut fractures occur, they should be repaired immediately to prevent significant deformity.  If it isn’t, the  cartilaginous septal segment will tend to rock posteriorly, resulting in a loss of dorsal support and a saddle-nose deformity.

Depending on the location of the fracture, it may be stabilized with either spread grafts or a combination of spreader grafts and
Kirschner wires.

Intracranial Injury and Cerebrospinal Fluid Leak Intracranial injury and cerebrospinal fluid leaks are a major complication after rhinoplasty.  They can happen with the cribiform plate it violated by surgical instruments or from excessive bony septum manipulation.  Either can result in a cerebrospinal fluid leak and potential intracranial injury or infection.

Symptoms of a cerebrospinal fluid leak include clear rhinorrhea and positional headache. The diagnosis may be confirmed by testing the fluid for the presence of 2-transferrin, a protein highly specific for cerebrospinal fluid. A

Treatment requires hospitalization, bed rest, and prompt otolaryngologic and neurosurgical evaluations.

Epiphora  --  after rhinoplasty is most commonly occurs due to compression of the lacrimal system by the soft-tissue edema.  It normally resolves after 1 to 2 weeks.

Functional Complications

Septal Perforation -- are most often caused by opposing tears in the elevated septal mucoperichondrial flaps with no  intervening septal cartilage.   They may also result from decreased blood flow to those same flaps from an unrecognized septal hematoma or tissue necrosis from septal stitches.

Symptoms of a nasal septal perforation include crusting, bleeding,
whistling, and nasal airway obstruction due to disruption
of the normal laminar airflow through the nasal passages.

Treatment includes

• Local hygiene with nasal saline irrigation
• Obturation with a Silastic septal button
• For small perforations, local advancement flaps with an interposed connective tissue autograft or an allograft can be
  used to close the perforation.

Intranasal Adhesions  -- (synechiae ) result from cicatrical healing of opposed, abraded mucosal surfaces.

Patients may present with nasal obstruction. Intranasal examination will reveal a “bridge” of mucosa from the septum to the inferior turbinate, middle turbinate, or lateral nasal wall.

Treatment requires division and placement of a barrier between the incised surfaces, such as a Silastic splint, until the surfaces undergo complete re-epithelialization.

Postoperative Septal Deviation  -- whether new or uncorrected, following septorhinoplasty is a source of frustration for both the patient and the surgeon.  Any significant septal deviation that persists and causes cosmetic or functional impairment may require revision surgery.

Rhinitis – Atrophic rhinitis is due to atrophy of the nasal mucosa usually due to overresection of intranasal structures such as the middle or inferior turbinate.

Patients often present with subsequent symptoms of dryness, crusting, and nasal obstruction.  These patients will get relief with nasal saline.

Patients may also report a spontaneous clear watery nasal discharge.   This phenomenon is most likely due to  a variant of vasomotor rhinitis caused by abnormal parasympathetic tone to
the intranasal mucosa.  These patients are often effectively treated with topical anticholinergic preparations, such as 0.03% ipratropium bromide  which act locally to decrease the watery rhinorrhea.  The recommended dosing regimen is two sprays in each nostril two to three times a day as needed.

Continued symptoms of watery nasal discharge despite appropriate topical therapy should raise the concern for an occult cerebrospinal fluid leak.

Aesthetic Complications

Tip and Dorsal Deformities
Postoperative deformities of the osseocartilaginous framework may be caused by overresection or underresection of the osseocartilaginous framework, incorrectly performed osteotomies, incorrect shaping of grafts and their edges, and migration of grafts due to insufficient or inaccurate fixation.

Persistent tip or dorsal deformities are generally not treated until at least 1 year after the previous rhinoplasty.

Supratip (“Pollybeak”) Deformity -- is a postoperative complication of rhinoplasty in which the nasal supratip assumes a convex shape in relation to the nasal dorsum. The deformity results either from inadequate resection of the lower dorsal septum and upper lateral cartilages or, paradoxically, from overresection of these supratip structures with subsequent scar tissue formation in the resulting dead space.

Patients who develop supratip fullness should be instructed to apply compressive tape onto the supratip area nightly. This is generally effective in treating transient postoperative swelling.  Taping should be discontinued when a permanent depression is obtained.

Steroid injections can improve excessive swelling and reduce scar tissue in the supratip area.  The injections can be used in patients who continue to supratip fullness despite compressive taping.  Triamcinolone acetate,  1 to 2 mg, is injected below the
dermis in the supratip area.  The injections may be repeated at 2-month intervals until an aesthetically pleasing supratip contour is obtained.

Side effects of the steroid injections should be remembered.  The most frequent is dermal atrophy, which may lead to a contraction
deformity of the skin. Other side effects include telangiectasias, depressions, color changes, and eventual visibility of the underlying cartilages or contour imperfections, which may be enhanced by the resulting decrease of skin thickness.

Corrective surgical procedures should not be performed until
at least 1 year after the initial procedure. 

The basic principles include judicious removal of the offending cartilage or scar tissue, adjustment of the osseocartilaginous framework so that the differential between the midvault and the tip is adequate, elimination of dead space by establishing direct contact between the underlying framework and the skin, and application of a dressing with selective compression over the supratip area.

Soft-Tissue Complications
Postrhinoplasty Nasal Cysts  -- are a rare complication
of rhinoplasty. The most common site of occurrence for both types of cysts is the nasal dorsum.  Both may require complete excision.

• Lipogranulomas or “paraffinomas” are foreign-body inclusion cysts that are thought to arise from the use of petroleum-based
  ointments in conjunction with nasal packing.
• Mucous cysts are a second type of nasal cyst that can arise after rhinoplasty. They are thought to arise from ectopic or displaced mucosa and ointment extravasation into osteotomy sites.

Contact Dermatitis and Skin Necrosis --

Contact dermatitis may result from irritation of the skin by the topical adhesives, tape, or dorsal splint. It usually resolves without any permanent sequelae.

Treatment of contact dermatitis

• removal of the offending agent
• application of topical and potentially systemic steroids,
  depending on the severity of the reaction.

Superficial skin necrosis or epidermolysis can occur secondary to excessive compression of the skin by the taping and dressing.  More problematic is partial-thickness or full-thickness skin necrosis that can occurs when the blood supply of the soft-tissue envelope is severely embarrassed. 
Treatment of minor skin necrosis should initially be conservative.

• Daily wound care, allow the wound to close by secondary intention
• Protection from the sun
• After maturation of the scar, dermabrasion, filler substances, skin care, and laser treatment may be helpful.

Telangiectasias -- are small superficial vessels of the skin visible to the human eye and usually measure 0.1 to 1.0 mm in diameter.  Argon and pulsed dye lasers have proven to
be an effective means of treatment.

REFERENCE

Prevention and Management of Rhinoplasty Complications;  Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 60e-67e; Cochran, C Spencer M.D.; Landecker, Alan M.D.

Myofascial Compartments of the Hand in Relation to Compartment Syndrome --- an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Acute compartment syndrome of the hand is an emergency and  requires prompt surgical decompression.  This article (the first reference below) is a cadaveric study aimed at identifying the myofascial compartments of the hand.  As they point out

Few studies have outlined the myofascial compartments of the hand. The standard anatomy texts do not show actual anatomical specimens but instead rely on diagrams and figures to outline the various compartments. These include the thenar, hypothenar, adductor, and interosseous compartments, each encased in fascia that extended from one metacarpal to another

The ten anatomical compartments of the hand include (photo credit)

• four dorsal interossei
• three palmer interossei
• adductor pollicis
• thenar
• hypothenar

The authors dissected fourteen fresh-frozen cadaveric hands.  They found no distinct tough fascia completely surrounding any of the intrinsic muscles, but instead thin filmy fascia that partially encases some of the muscles. 

Results:
There was no well-defined tough fascia overlying the thenar muscles, the hypothenar muscles, or the adductor pollicis.
Areolar tissue was present between the individual thenar and hypothenar muscles.
A distinct band of fascia was noted over the entire length of the ulnar three dorsal interosseous muscles.
A band of fascia was noted over the distal portion of the palmar interossei but not over the proximal aspect.
The above findings were found in all 14 specimens.
A layer of loose areolar tissue was noted over the dorsal aspect of the first web space in eight specimens, whereas a distinct band of fascia was noted overlying the first dorsal interosseous muscle in the remaining six.

Interesting findings, but doesn’t explain why it is necessary to do the fasciotomies in each and every compartment.  Does the skin constrict that much?  Maybe.



REFERENCES

Myofascial Compartments of the Hand in Relation to Compartment Syndrome: A Cadaveric Study; Plastic and Reconstructive Surgery:Volume 123(2)February 2009, pp 613-616; Ling, Marcus Z. X. M.B.B.S.; Kumar, V P. F.R.C.S.

Beware: Compartment Syndrome of the Hand; JNZMA, Feb 11, 2005, Vol 118, No 1209; Warren Leigh, Vasu Pai

Compartment Syndromes of Hand and Forearm; Wheeless' Textbook of Orthopaedics; Last updated by Clifford R. Wheeless, III, MD on Sunday, December 28, 2008 8:31 pm

Compartment Syndrome, Upper Extremity; eMedicine Article, July 27, 2007; Stephen Wallace, MD and Douglas G Smith, MD

Sulfonamide Associated Hepatic Failure

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

First off, let me say I have never seen this complication of sulfonamides.  I was only vaguely aware that it existed.  A patient came in to discuss a cosmetic procedure.  Like always, I was going through the allergy section.  She had marked yes on the sulfa drugs.  I asked what kind of reaction.   I want to know if it was a true problem or just an unwelcome side effect.

She then told me about her son who died of acute hepatic failure from a reaction to Bactrim (Sulfamethoxazole/Trimethoprim), and how a few years after his death she got very ill after taking Bactrim.  So now their family refuses to take sulfa drugs.  It prompted me to do a review.

Sulfamethoxazole/Trimethoprim (SMX/TMP) is a commonly used antibiotic for respiratory, gastrointestinal and urinary tract infections caused by a range of aerobic gram-positive and gram-negative bacteria. It also has activity against Listeria monocytogenes, Nocardia and Pneuomcystis jiroveci.

SMX/TMP is generally well tolerated in non-HIV-infected patients.  Adverse reactions occur in this group in approximately 6 to 8 percent of individuals. In comparison, the adverse reaction rate is as high as 25 to 50 percent in HIV-infected patients and many of the reactions are severe.

The most common adverse reactions include nausea, vomiting, anorexia, dermatological reactions such as pruritis, urticaria and less commonly Steven Johnson Syndrome.

Life-threatening adverse reactions include neutropenia, exfoliative dermatitis (a severe skin disorder with generalized erythema and scaling) and toxic epidermal necrolysis (an acute severe reaction with widespread erythema and detachment of the epidermis). Acute liver failure has only been reported in a few cases worldwide, and has been attributed to the sulphonamide component of the drug.

The sulfamethoxazole component of SMX/TMP is responsible for most of its' side effects including liver failure.
Three forms of SMX/TMP induced liver damage have been described.
1) hepatocellular
2)  mixed hepatocellular cholestatic
3) bile duct injury with ductopenia or Vanishing Bile duct syndrome

The onset of symptoms usually occurs within a few days of exposure, but can take up to a 1–2 months.  Patients will usually present with  nausea, vomiting, jaundice, and pruritis (if cholestatic).  Liver function tests (LFTs)  may show a hepatocellular or cholestatic pattern depending on the type of injury. Patients might have other feature of an allergic reaction such as skin rash, eosinophilia. 

Diagnosis is suspected from the clinical presentation, and absence of other causes.

The severity of SMX/TMP induced liver injury can range from mild symptoms with elevated liver enzymes to fulminant hepatic failure with hepatic encephalopathy and coagulopathy. Outcome can be favorable with spontaneous resolution or unfavorable leading to death.

Treatment is generally supportive, liver transplantation has been successful for both fulminant hepatic failure and vanishing bile duct syndrome

REFERENCES

Acute Liver Disease Associated with Erythromycins, Sulfonamides, and Tetracyclines; Annals of Internal Medicine, Vol 119, Issue 7, Part 1, pp 576-583, Oct 1993;  Jeffrey L. Carson; Brian L. Strom; Amy Duff; Anand Gupta; Michele Shaw; Frank E. Lundin; and Kiron Das

Case Report: Sulfamethoxazole/Trimethoprim induced liver failure: a case report; Cases Journal 2008, :44doi:10.1186/1757-1626-1-44; Salaheldin Abusin, Swapna Johnson
Harrison’s Online; Chapter 299 (Merck’s)-- Trimethoprim-Sulfamethoxazole Hepatotoxicity (Idiosyncratic Reaction)

Refinements in Nasal Reconstruction – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

The article “Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap” and the “discussion” both recently published in the Journal of Plastic and Reconstructive Surgery (see full references below) give a truly nice review of the procedure.

Nasal reconstruction is often challenging. The forehead flap is a workhorse flap in nasal reconstruction. It provides similar skin color, texture, structure, and reliability. A disadvantage of the forehead flap includes a difficult arc of rotation. This can displace the medial eyebrow hair. The vertical design can encroach on the scalp which can risk incorporating unwanted hair into the nasal reconstruction.

Historically, the median forehead flap was based on a wide pedicle whose base sit in the center of the forehead. Both supratrochlear vessels were included. This pedicle did not extend below the eyebrows. This wide pedicle had the potential to increase the torsion on vessels which could then lead to compromising the blood flow to the flap.

The paramedian flap design is centered directly over the supratrochlear artery (note: only one vessel, not both) above the medial side of the eyebrow. The proximal flap does not extend below the eyebrow, resulting in shorter flap length.

The midline forehead flap combines features of both the median and the paramedian forehead flaps. The skin paddle is centered in the midline based on a unilateral supratrochlear vessel. The pedicle can be dissected at its emergence from the superior medial orbit.

The article describes the authors' modification of the established oblique paramedian forehead flap.

Stage 1

The cross-paramedian forehead flap is based on the supratrochlear vessel contralateral to the nasal defect. The flap is designed to extend across the midline of the forehead to the contralateral side. The flap is an axial pedicle flap until it crosses the midline. The distal third of the flap crosses the midline to become a random flap.

The flap is elevated in the subgaleal plane from distal to proximal to the supraorbital region. The dissection plane becomes subperiosteal at the level of the upper eyebrow. Inferior dissection is carried into the orbit in the subperiosteal plane to facilitate a safe arc of rotation without tension.

The periosteum is incorporated at the most inferior extent of the pedicle and carefully freed toward the supratrochlear vessels to facilitate flap rotation. The pedicle is designed with a narrow skin bridge 8 mm in width with a sufficiently wide subcutaneous and galeal pedicle to safely include the supratrochlear vessels. The narrow skin pedicle is carried below the medial eyebrow toward the medial canthus.

The forehead flap is mobilized and rotated downward into the nasal defect. If the flap appears robust, the frontalis muscle can be thinned from the distal half. The flap is folded on itself distally to replace the nasal lining if necessary. This design provides a longer hairless flap, which is advantageous when reconstructing lining. The donor site is closed primarily. We prefer to base the pedicle on the contralateral side of the defect because it provides a smooth arc of rotation and a longer non-hair-bearing flap.

Stage 2

The flap is divided and inset at 2.5 to 3 weeks. The skin width is narrow proximally and is excised in or parallel to the glabellar frown line. This results in a linear scar in the glabella region.

Secondary refinements of the forehead flap may be necessary to defat the flap and refine the aesthetic contour.

Both article and discussion are worth your time to read and study.
REFERENCES

Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery:Volume 123(1)January 2009, pp 87-93; Angobaldo, Jeff M.D.; Marks, Malcolm M.D.

Discussion of Refinements in Nasal Reconstruction: The Cross-Paramedian Forehead Flap; Plastic and Reconstructive Surgery; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 94-97; Menick, Frederick J. M.D.

Splinting after CTR – an Article Review

 Updated 3/2017--all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I admit, I splint after carpal tunnel release (CTR), though after reading this article I will change my ways. My use of splints after CTR has been because “I was taught that in training”. Not always a bad thing, but not always a good thing either. I was reminded of this by the opening of the article (first reference below):

Dogma is pervasive in all of medicine, and hand surgery is no exception. As the movement toward evidence-based medicine continues, clinical researchers have striven to dispel dogmatic practices for which no scientific support exists. One such target is the practice of splinting after carpal tunnel release. There have been five prospective, randomized trials, all since 1995, showing that postoperative splinting after this procedure is of no benefit, with one of them demonstrating that it is actually detrimental.

I have not read the five articles (2 – 6 references below) they mention in the opening above.

The authors sent a questionnaire to all members of the American Society for Surgery of the Hand (2257 total). They excluded residents, fellows, and supporting members. Recipients were asked whether they splint their patients in the immediate postoperative period after CTR, and if so, for how long they maintain the splint. They were also asked to indicate their training (i.e., orthopedic, plastic, or general surgery).

Of the 2257 questionnaires mailed, 1091 were returned (48% response). Sixty-nine percent of respondents were trained in orthopedic surgery, 16 percent were trained in plastic surgery, and 3 percent were trained in general surgery. An additional 2 percent were trained in both orthopedic surgery and plastic surgery. These percentages are congruent with the overall American Society for Surgery of the Hand membership profile. Ten percent of respondents did not specify their specialty.

The results were similar regardless of the specialty:

Fifty-three percent of respondents use full-time splinting postoperatively.

Five percent of these respondents also prescribe the use of night splints after a variable period of full-time splinting.

Night splinting is used as the only postoperative immobilization by 1 percent of respondents (night splinting was not offered as an option on the questionnaire so may be underrepresented as it required a write-in response)

In addition, 1 percent of respondents wrote that they apply a bulky dressing. This practice was not counted as splinting.

Within the subset of surgeons who apply splints after carpal tunnel release, there is tremendous variation in splinting duration, with a range of 1 day to 6 weeks.

The duration reported most frequently (i.e., the mode response) within this subset is 7 days.

It is noteworthy, however, that when considering the entire survey population, the most frequently reported duration is, decisively, 0 days (i.e., no splinting).

In their discussion section, the authors reviewed the five articles (2-6 references below) that show no advantage and some disadvantage to postop splinting. Here is what they say in summarizing the article by Cook et al

In the first of these trials, Cook et al randomized 50 patients undergoing open carpal tunnel release to be splinted for 2 weeks postoperatively or to begin unrestricted active motion on the first postoperative day.
The drawbacks of immobilization were striking. At 1-month follow-up, the splinted group fared significantly worse with respect to the incidence of scar tenderness and pillar pain, patients' subjective pain rating, grip and key pinch strength, and patients' assessment of outcome.
Even more conspicuous was the splinted group's slower return to activities of daily living (12 days versus 6 days; p = 0.0004) and light-duty work (27 days versus 17 days; p = 0.005).
There were no wound complications, hematomas, bowstringing or adherence of flexor tendons, or neuromas in either group.
The authors concluded that splinting is largely detrimental but acknowledged that certain rare complications, such as bowstringing, might occur in a larger series. They recommended early mobilization but advised against simultaneous finger and wrist flexion, which might be more likely to result in bowstringing

The prevention of flexor tendon bowstringing is frequently cited as the reason for splinting after carpal tunnel release. The authors of this survey article notes that

To our knowledge, this complication has been reported only once, in a 1978 article by McDonald et al. In their series of 186 carpal tunnel releases, bowstringing was observed in two patients. Interestingly, these patients were splinted postoperatively, and in both cases the bowstringing occurred after reoperative carpal tunnel release.

In their words, Bowstringing of the flexor tendons is a rare complication, possibly occurring as a result of removing a segment of the transverse carpal ligament or from inadequate immobilization following a carpal tunnel release.

Splinting seems like such a small thing to worry over, but it is important to question the reason we do things. To be sure we do them for the correct reasons. To be able to base them on current scientific standards. To continue to learn.

REFERENCE

1. Splinting after Carpal Tunnel Release: Current Practice, Scientific Evidence, and Trends; Plastic & Reconstructive Surgery:Vol 122(4), Oct 2008, pp 1095-1099; Henry, Steven L. M.D.; Hubbard, Bradley A. M.D.; Concannon, Matthew J. M.D.

2. Cook, A. C., Szabo, R. M., Birkholz, S. W., and King, E. F. Early mobilization following carpal tunnel release: A prospective randomized study. J. Hand Surg. (Br.) 20: 228, 1995

3. Bury, T. F., Akelman, E., and Weiss, A. P. C. Prospective, randomized trial of splinting after carpal tunnel release. Ann. Plast. Surg. 35: 19, 1995

4. Finsen, V., Andersen, K., and Russwurm, H. No advantage from splinting the wrist after open carpal tunnel release: A randomized study of 82 wrists. Acta Orthop. Scand. 70: 288, 1999

5. Bhatia, R., Field, J., Grote, J., et al. Does splinting help pain after carpal tunnel release? J. Hand Surg. (Br.) 25: 150, 2000

6. Martins, R. S., Siqueira, M. G., and Simplicio, H. Wrist immobilization after carpal tunnel release: A prospective study. Arq. Neuropsiquiatr. 64: 596, 2006

7. McDonald, R. I., Lichtman, D. M., Hanlon, J. J., et al. Complications of surgical release for carpal tunnel syndrome. J. Hand Surg. (Am.) 3: 70, 1978.

Scars and Their Therapy – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

As I continue to catch up on my journal reading, I thought I would review and share this (full reference below) article with you on scars and current therapies.

The article begins by touching on the three stages of wound healing:   inflammation, proliferation, and matrix remodeling/scar formation.  Then goes on to discuss first the emerging scar-reducing therapies and then the currently available therapies.

The list and discuss the following as emerging scar-reducing therapies:

TGF-β Superfamily--

TGF-β has been studied as a potential scar-reducing agent since the 1980s.  TGF-β1, TGF-β2, and TGF-β3, have been demonstrated to have major roles in scar production.   Investigations of TGF-β as a scar-reducing agent have sought to simulate the fetal wound-healing environment by increasing the relative ratio of TGF-β3 to TGF-β1 and TGF-β2 to minimize scarring.  There are several ongoing Phase II clinical trials evaluating Juvista, human recombinant TGF-β3, with the next trials due to report in mid 2008. Although demonstrating positive preliminary efficacy with high safety, it remains to be seen with great anticipation what the long-term efficacy in larger trials will be compared with current therapy and what practical role if any TGF-β-modulating agents will play in future therapeutic protocols.

COX-2 Inhibitors and Nonsteroidal Antiinflammatory Drugs:

There has been growing interest in the role of the COX-2 pathway in scar reduction.  Topical application of a selective COX-2 inhibitor immediately after wounding resulted in a statistically significant reduction in local neutrophils, prostaglandin E₂ levels, TGF-β1, collagen deposition, and scar formation in a mouse study.  Of note, it has been demonstrated that topical application of COX-2 inhibitors does not have a negative effect on wound reepithelialization.  There is conflicting evidence on the effect of constitutive inhibition of COX-1 and COX-2 on wound healing. One study has suggested that inhibition of COX-1 may cause delayed wound healing, whereas another study demonstrates no delay in wound healing.

Collagen Synthesis Inhibitors

Modulation of collagen metabolism is another potential target for preventing excessive scar formation. ……………. has shown modest benefit of scar reduction to date, and these remain agents of interest for further investigation.

Angiotensin-Converting Enzyme Inhibitors

It is well accepted in the cardiovascular literature that up-regulation of angiotensin-converting enzyme participates in adverse fibrous cardiac remodeling.   Recent studies have shown that a locally functioning tissue renin-angiotensin system operates in human skin.  It has been demonstrated that exogenous angiotensin II may accelerate wound healing in animal models.  ……… Further investigation of their role in scar reduction is warranted.

Minocycline

A recent study found that systemically administered minocycline significantly reduced the severity of hypertrophic scarring in a rabbit ear scar model.  The mechanism by which minocycline reduces scar formation in this model remains unanswered. …… Additional studies are needed to elucidate the mechanism of this intriguing agent.

Gene Therapy

There have been few published studies, limited to animal models, using gene therapy to investigate scar reduction. To date, fibroblasts have been used as the primary targets for a gene therapy approach to scar reduction. A major obstacle is that scarring is a very complicated process involving many different factors, and much of the outcome of scar formation is likely programmed by the early inflammatory response to wounding. Most studies to date have demonstrated modest or inconclusive results on scar formation.

They list and discuss the following as currently available scar-reducing therapies:

Topical and Intralesional Corticosteroid Injections

Triamcinolone is currently the most commonly used corticosteroid for the treatment of scars. When used as a monotherapeutic agent, studies show 50 to 100 percent efficacy of intralesional injection of triamcinolone.  However, many of these studies lack well-designed controls and standardized objective measures of scar outcome and thus are of limited value………

5-Fluorouracil

Use of intralesional 5-fluorouracil for treatment of hypertrophic scars has been shown to be effective in multiple studies.  However, most of these studies lack adequate controls and are of limited value. Combinations of 5-fluorouracil with intralesional corticosteroids and pulsed dye laser have been used to achieve better results than 5-fluorouracil as a monotherapy.  Notably, the combination of 5-fluorouracil with corticosteroids has been shown to decrease the side effects related to prolonged therapy with corticosteroids alone. …….

Bleomycin

Bleomycin is an antibiotic with well-known antitumor, antibacterial, and antiviral activity.  Studies have shown that intradermal injection or the multipuncture method of bleomycin injection results in significant improvement in keloids and hypertrophic scars.  However, all of these studies involved a small sample size and lack well-designed controls and thus are of limited value.  ……

Adverse sequelae of bleomycin include hyperpigmentation (75 percent) and dermal atrophy in the skin surrounding treated scars (10 to 30 percent).  Further large controlled trials are needed to evaluate the efficacy of bleomycin.

Laser Therapy

Pulsed dye laser therapy has been shown to have positive efficacy in numerous studies, but many of these studies lack well-designed controls and are of limited value. The primary indication for pulsed dye laser is to reduce erythema. Pulsed dye laser therapy is based on the principle that hypervascularity plays a key role in scar appearance. ……

Common side effects of pulsed dye laser treatment include posttreatment purpura, which usually subsides after 7 to 10 days, and hyperpigmentation in 1 to 24 percent of patients.  ……… if further controlled trials support its efficacy.

Silicone Gel Sheets

Numerous studies have demonstrated the utility of silicone gel sheeting in treating hypertrophic scars but overall yield inconclusive evidence for its mechanism of action and efficacy in reducing existing scars.   Silicone gel sheeting has also been investigated for its potential utility in scar prophylaxis when applied in the postoperative period. Controlled studies investigating silicone gel sheeting applied to wounds immediately and 2 weeks postoperatively significantly decreased scar volume over controls in mirror-image incisional wounds. However, the largest controlled study demonstrated no improvement in scar prophylaxis.   A recent Cochrane review cites 13 trials involving 559 patients and concludes there is weak evidence of a benefit of silicone gel sheeting as a prevention for abnormal scarring in high-risk individuals, but most studies are of poor quality and highly susceptible to bias…….

Pressure Therapy

Pressure therapy has been a conservative management of scars since the 1970s,  despite a paucity of well-designed controlled clinical studies demonstrating its efficacy. ……..The largest randomized controlled trial showed no significant differences in scar reduction with pressure therapy compared with controls.

Current evidence does not support the efficacy of pressure treatment as a monotherapy for scar reduction. The appropriate role of pressure therapy in scar reduction protocols may be as an adjunctive treatment as part of a polytherapeutic strategy of scar management, but this must first be evaluated in clinical studies.

Cryotherapy

There have been many reports of cryotherapy used as a combination therapy with surgical excision for hypertrophic scar and keloid reduction.   Most of these studies are difficult to evaluate because of small sample sizes and lack of adequate controls. …… The main adverse effects reported were atrophic depressed scars and residual hypopigmentation (75 percent of cases).   ….. there is limited evidence for the long-term efficacy of cryotherapy for scar reduction.

Radiation

Radiation therapy has been used in scar management primarily in the treatment of keloids, frequently being used as an effective adjunct to surgical excision.  Radiation likely mediates its effects on keloids through inhibition of proliferating fibroblasts and neovascular bud formation, resulting in decreased collagen production. 

Surgical excision in combination with radiotherapy is considered the most effective treatment available for severe keloids. There is limited and inconclusive evidence regarding optimal dosage, fractionation, indications for treatment, or timing of radiotherapy with respect to surgical procedures. However, a single dose given within 24 hours of excision appears to yield the highest cure rate in recurrent keloids. …….

Surgical Treatment

There are many different surgical strategies for scar revision, including excision with linear closure, excision with split- or full-thickness skin grafting, Z-plasty, W-plasty, and if all other options fail, excision followed by flap coverage. Tissue expansion and serial scar excision may be used to provide more tissue for advancement or local flap coverage of revised scars……

The article is well written and is a nice review of scar therapies.  I would have to agree with their conclusion that

There is a great need to use large controlled trials to examine currently available and emerging strategies of scar reduction to standardize scar treatment protocols and evaluate emerging agents that could potentially benefit patients with scars refractory to currently available treatments.   Two major shortcomings of current clinical studies include (1) a lack of well-designed controls and (2) a lack of standardized and comprehensive evaluative measurements of scar outcome.

REFERENCE
Scars: A Review of Emerging and Currently Available Therapies; Plastic & Reconstructive Surgery. 122(4):1068-1078, October 2008; Reish, Richard G. M.D.; Eriksson, Elof M.D., Ph.D.

Other related posts:
Skin – Healing a Simple Wound/Laceration
Scar Prevention

Maggot Therapy

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Recently read a new article (the sixth one in the references below) on “maggot therapy” and couldn’t resist updating the one I first did in October 2007.

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization.

W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy.

A drawing of the life cycle of this fly appears below.

One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons.

It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day.

They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus).

Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Maggots must be disposed of as infectious waste in a biohazard bag when finished.  It is best to double-bag and seal the removed maggots.

From the sixth reference article regarding use of maggots in the United States:

Maggots are available only by prescription.

The Food and Drug Administration regulates the use of medical maggots, as not all species are therapeutic or safe.

Approved use currently exists for the debridement of non-healing necrotic skin and soft tissue wounds that include pressure ulcers, venous ulcers, neuropathic foot ulcers, and non-healing traumatic or postsurgical wounds.

In the United States, the supplier of Medical Maggots is Monarch Labs in Irvine, California. A vial of 250 to 500 larvae costs approximately $88 plus shipping and handling.  The number of vials needed will be determined by the wound size and duration of therapy. Many wounds require only 1 to 2 applications over a 3- to 7-day period.

REFERENCES

1.  Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

2.  From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

3.  Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

4.  Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

5.  Maggot Therapy for Wound Management; Advances in Skin & Wound Care:Vol 22(1),Jan 2009, pp 25-27; Hunter, Susan RN, MSN; Langemo, Diane PhD, RN, FAAN; Thompson, Patricia RN, MS; Hanson, Darlene RN, MS; Anderson, Julie PhD, RN, CCRC

7.  Maggots Are Enough to Gag Superbugs; Wall Street Journal Article August 8, 2008;  by Scott Hensley (Don’t watch the video in the article if you are squeamish.)

My Old Blog Posts
Maggot Therapy, October 31, 2007
Maggot Therapy Revisited, August 11, 2008